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Tuberculosis, or TB, is an ancient disease that has been with us from the very start. It’s been found in Peruvian mummies, Egyptian mummies, and burial sites that are almost 10,000 years old, at least in DNA form, and it’s still, today, the single deadliest infectious disease, killing almost a million and a half people a year, back on top this year after COVID played the part of Leicester City in 2020. It has infected about a quarter of the world’s population. We’ll come back to that briefly at the end just to cause some existential dread and we’ll have some links for more reading, but forget all that stuff, what we really want to know is how it affected Victorian England, which I think we’ve established is one of this podcast’s favorite eras–in this case, because it was nutty enough to take the symptoms of this disease and essentially proclaim it sexy as all hell while everyone first tried to figure out what it was, then tried to figure out what to do about it. Let’s do a bit of background, keeping in mind, in the US, as a modern ED doc, I’ve seen probably fewer than five cases of TB. If you’re listening or have a background in Global Medicine, feel free to point out stuff I get wrong for a future shout-out! TB is typically caused by mycobacterium tuberculosis, which is a bacterium, and part of a group of seven or eight closely related bacteria, all of which generally cause similar disease. TB is, first off, really slow. Some bacteria replicate in 20 minutes, but TB takes up to a day to replicate. It also needs lots of oxygen. Its cell wall is basically solid fat. It also doesn’t like to move. Because of all those factors, it tends to set up in the lungs–we’re essentially the only victim of this disease–some forms get into livestock, but really it’s all us. It’s able to trick the immune system into bringing it lunch instead of killing it once it’s absorbed, so it creates these giant cavitary lesions and clumps of cells and gunk from us trying to kill the cells called a granuloma generally, and they get quite large. Characteristically it goes for the upper lungs because that’s where the oxygen is richest. Lazy. This is the laziest bacterial disease I’ve ever heard of. E. Coli is clawing its way up the urethra and TB is just sitting there. Complete trash. A relatively high percentage of people don’t even develop active disease if they are infected–90 percent of people who have normal immune systems control the bacterium after infection and develop no symptoms–and although it’s definitely contagious, it takes a fair amount of exposure to catch it–which is not to say it’s not a problem or safe or whatever. It’s more like that picture of the iceberg where most of it is below the water that you see in PowerPoint shows, with a huge number of people infected but not sick, and even when they are, it takes weeks before they start to show symptoms. Because it’s a slow bacterium, TB is likewise a slow disease, usually, with an initial phase that lasts weeks. The ‘post-primary’ phase often lasts for years, outside of what was called ‘galloping consumption’, and outside of other infections like HIV, and primarily consists of a losing battle between the body and the bacteria. You can kill it with antibiotics but it takes, like, four of them, if you’re lucky, and treatment goes on for months. People are intermittently contagious early on, as the body’s immune system tries and usually fails to clear disease. People then devolve into this classic picture of weight loss and what’s called cachexia, with night sweats, and a bloody cough that Hollywood loves. Most of the consequences have to do with destruction of the lungs, but because it is incompletely cleared and can travel through the bloodstream, it can set up and cause granulomas all over. Today, it’s relatively rare in rich countries, so we don’t see it, and thus we don’t care about it as much as we should in general; the WHO still does, and global health does, but there is a whole historical era heavily influenced by tuberculosis–nineteenth century England. There was a bunch of heinous crap in those days, as we’ve covered, and you could die in all sorts of ways, but tuberculosis captured the imagination in a way few other diseases can rival. Starting in the seventeenth century, people noticed that TB was more and more prevalent, and took to calling it ‘consumption’ because it does literally consume patients–people can’t keep up nutritionally and they lose weight to a staggering degree. In the early 1800s, there was a mandate from parliament to track vital statistics, such as mortality rates, cause of death, and so on. This led to a lot of writings about TB overall, with estimates that the disease accounted for anywhere from a fifth to a third of deaths at the time, probably heightening its fame. TB also coincided with our old friend Theophile Hyacinth Laennec’s invention of the stethoscope, which allowed a significant extension of the physical exam, especially of the lungs, where there were numerous findings in TB patients. In combination with growing anatomist studies which we’ve also covered, there was a whole cottage industry of TB prognostication and guesswork, including new names for types of dead tissue–caseating necrosis is a description of dead tissue in the body that looks like cheese, for example–and many autopsy findings to name in TB patients. Because it was so common, many experts had a lot to say about it, always good for fun with an infectious agent before germ theory. Of course the Victorian English, being Victorian English, related TB to what they called ‘constitutional factors’ which was really just cover for a sort of class-based or inherited theory–you’re sick because you’re inferior, the thinking went. This seemed to be the prevalent view in England and northern Europe, for some reason, while TB was regarded as more infectious in the south. Perhaps because the disease was slow, and some percentage cleared the disease even when infected, people looked for explanations other than contagion; as early as 1806, the doctor John Ried said, “the destroying angel, while requiring general retribution for certain deviations from nature, marks particular individuals for primary sacrifice”. This was reinforced with cases like the Bronte family; Emily Bronte, who penned the famous Wuthering Heights, her only novel, published to great acclaim in 1847, was one of the younger sisters. It was her only book, and it was apparently so passionate everyone thought a man wrote it at first. Her whole family died of TB, and rather than look at the fact that they all drank water that drained out of the church graveyard next door or that, you know, TB is contagious, chose to say, oh, well, she was quiet, shy, and retiring, and obviously didn’t have a strong constitution, that must have been passed on to her by her family. Prescriptions for things to strengthen the constitution are thus explained, and, likely, appropriate, because the disease wasn’t curable anyway and ‘medicine’ at the time certainly wasn’t going to cure it! Sea-bathing was a popular one. Horseback riding was popular for hundreds of years–Thomas Sydenham popularized it in the 1600s (sound familiar?), with the dual benefit of exposure to the open air and ‘gentle stimulation of the constitution’. Anything that was stimulating but not over-taxing–swinging, which required little exertion, or sailing were often prescribed. Some rich folks took off on sailboats to Spain. Climate, too–led to examples like Dr. James Clark, who, in the early 1800s, moved to the south of France and eventually set up a clinic in Rome for English people looking to get healthy, and led to the whole sanatorium movement, where specific hospitals or retreats were made in warm climates to help people recover. This is a whole different episode, maybe TB part II, as the sanatorium movement helped grow the hospital movement, and was a look into class differences as well, since pauper ‘sanatoriums’ were quite different from those in the south of France. Fun shout out to Arizona, where Tucson was so popular as a sanatorium destination in the US during TB’s height that people ended up forming tent cities of TB patients outside the city once the multiple sanatoriums filled up. In addition to steps to improve the patient’s constitution, there were any number of direct therapies. There was a ‘consumptive diet’ which included large amounts of fat, which is called suet in the Victorian Era, usually from a specific animal because, as we all know, the best suet is mutton suet. Asses’s milk was very popular for some reason. They tried all sorts of medicines; arsenic and mercury were thankfully used less frequently than quinine–an alkaloid made from Cinchona trees against malaria still–and digitalis, or foxglove, which we’ve also covered. Both of these ‘helped’ by slowing the heart or ‘stopping’ fevers, but really not a great way to treat fever or tachycardia. So anyway that’s some of the medical background at the time, with this illness that is quite fascinating, and kills up to 80% of people that don’t clear it right away and accounts for a quarter, give or take, of deaths in London in the 1800s. The English, though, took this slow-moving epidemic and turned it inside out in a sort of mass cultural delusion which has a few points to discuss. First off, TB was romanticized to a tremendous degree. Emily Bronte was one example of how ‘dying of consumption’ was romanticized by the literary set, since she was the Amy Winehouse of books and only ever published one. Keats, one of the most famous so-called Romantic poets at the beginning of the eighteenth century died of TB. Keats wrote odes to melancholy and the transience of life. Byron, another famous poet and a contemporary of Keats, who wrote ‘she walks in beauty’, a famous pillar of English major life, noted at one point “How pale I look! – I should like, I think, to die of consumption … because then the women would all say, ‘see that poor Byron – how interesting he looks in dying!” Percy Shelly wrote to Keats at one point about this, and basically said, wow, looks like you still have TB, it sure likes us artistic types, doesn’t it? People took the idea that TB was related to constitution and applied it to standards of behavior and beauty in the upper classes; it was sort of assumed that it was a problem among the poor, which it was, but then, to the extent people died of TB among the upper classes, they would relate the infection to ways people were like the poor–linked to foul air, or living in the city when they could live in the country. Many if not all of these written opinions said women were more vulnerable than men because they were ‘indolent and inactive’. Physicians and others with opinions on TB linked lifestyle issues to TB with abandon, including the waltz when it became popular. As anatomists struggled to figure out what the nervous system did or how it worked, there was a whole concept of ‘sensibility’--like, an overactive nervous system–which was the cause of disease, and associated worry that a more refined life was leading to excitation of the nervous system, leading to a whole host of diseases, with TB among them. George Chyne, an English physician at the beginning of the Victorian Era, used this concept to turn health on its head and described what was called the ‘English Malady’--essentially, the price of England’s class, dominance, and wealth was a more excitable nervous system–that’s the sensibility–so that the very reason the English were so successful was the same reason they got sick. To some extent, if you were rich and sick, the sickness was a sign of how amazing you were. This extended to a whole host of maladies. In this setting, being sick with TB, previously romanticized and then linked to a sign of a superior nervous system, became fashionable. The fact that your pulse raced, you got pale and light-headed, and could barely deal with the slightest exertion, was in fact not malnutrition and low oxygen from advancing bacterial illness, but a sign that your nervous system was highly advanced, and actually proof of your high status. Fashion and beauty trends grew out of the above cultural underpinnings at the end of the nineteenth century, and the medical community happily took part. The London Medical and Surgical Journal in 1833, which basically said, in contrast to ‘uglier’ illness, ‘consumption, neither effacing the lines of personal beauty, nor damaging the intellectual functions, tends to exalt the moral habits, and exalt the amiable qualities of a patient’. Keep in mind, this is the description of a progressive bacterial illness that causes giant cheese-like lumps of dead white blood cells and bacteria throughout the body, leading to incessant coughing of blood and almost constant diarrhea until one dies of pneumonia. Fashion trends of the time focused on thinness and pallor as the beauty standards, which TB causes; corsets were used along with lots of other dress accessories to emphasize a slim waist, and make-up trends included rosy cheeks and pale skin. Projecting clavicles and wing-like scapulae were considered attractive, both of them a consequence of severe muscle wasting and what we call cachexia, which today can be seen in conditions that cause severe malnutrition. Writers were fully aware that TB was one of the causes emphasizing standards of beauty; one Victorian beauty essayist wrote that ‘in the last stage of consumption, a lady may exhibit the roses and lilies of youth and health, and be admired for her complexion the day she is to be buried’. It got to the point that medical texts would equate beauty with vulnerability to TB just as we consider high blood pressure a risk for heart disease today. Clothing trends throughout the 1800s were both pushed by this beauty standard and part of the debate over causation, because we all know clothing causes tuberculosis. Through the early 1800s, dresses exposed more skin, especially in the back, which was related to the scapula fashion, but was then attacked by many physicians as dangerous because we all know you catch cold when you go outside without suitable clothing. There’s so much discussion of wing-like shoulder blades in Victorian writing, either in favor or in disapproval. Women also stopped using flannel underwear which some physicians thought was quite dangerous. Lastly, corsets, which emphasized thin waists, were a huge point of debate, as they restricted both activity and, you know, breathing. I think it’s probably a great idea for the three of us to go on at length about fashion trends, right? There’s also a phenomenon called ‘tight-lacing’ which was prominent in use of corsets, by no means universal it looks like but common, that was condemned by many physicians as causative. Long trains on dresses were also blamed for kicking up dust that affected the lungs as women walked along dirt streets in London. This only intensified when Robert Koch isolated and identified the bacterium in the 1880s as the cause, at which point, other physicians said well the skirts must increase passage of the bacterium. I think it’s fair to say that men suffered equally from fashion trends when the voluminous beards of the late Victorian Era were largely attacked for the number of bacteria they held; Edwin Bowers, the doctor who pioneered reflexology, proved that even a blind squirrel finds a nut now and then when he said that ‘there is no way of knowing the number of bacteria and noxious germs that may lurk in the Amazonian jungles of a well-whiskered face, but their number must be legion’, blaming whiskers for tuberculosis, whooping cough, diphtheria, measles, and scarlet fever, to name a few. This led to a new clean-shaven fashion trend, especially among doctors, which is sad, because there are literally no beards like late nineteenth-century beards. Tuberculosis gradually declined in England for no good reason, really. It spread through the US as well a bit later, and, as I said, probably has fodder for another couple episodes with regards to the history it represents. Since I always like to end on an up note, just keep in mind that TB is deadlier than ever; most cases at this point occur in developing nations in Africa and Asia. There is a strong link to HIV, which potentiates infection. Because it’s so difficult to treat, we’re up to about 50 thousand cases a year of so-called XDR-TB, which is the X-games version of MDR-TB, or multi-drug resistant TB. The worst strains are resistant to multiple antibiotics, and are incredibly hard to treat. Our only good vaccine has a ton of real side effects and is only, right now, used in children and people with latent disease, I believe. Good times ahead with this still incredibly active disease. At least we can all die beautiful. References
Aaron Silver Fox Doc
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It’s National Osteopathic Medicine Week so what better time to dive into my own background. I, as a real, living, breathing Doctor of Osteopathy, will regale you with a history of my profession in medicine. This is something that has been a topic of particular interest to me and I’ve teased covering it for awhile. I will admit that I actually had no idea it was National Osteopathic Medicine Week and discovered that purely by coincidence while researching this show topic. That may show you how hardcore of an osteopath I really am. It’s fairly likely that many of our listeners may have been treated by a DO (doctor of osteopathy) at one point or another in their lives. My experience has been that patients usually don’t know I’m an osteopath until they squint at my badge and say the inevitable “What’s a DO?” line. It’s always vexing because I have to try and summarize the history of my wing of this profession in a soundbite while providing reassurance that I am, in fact, a real doctor and everything. I don’t imagine this happens to you guys. Though DOs are interchangeable with MD’s in all but title–you’ll find them doing family practice, internal medicine, and neurosurgery among all the other specialties–there is historic precedent behind the distinction of the title. DOs historically have wanted to maintain their DO-ness even as it’s been increasingly difficult to say what that distinctiveness is as we’ll find out. The DO difference all begins in response to a medical tragedy in 1864. A man named Andrew Taylor Still had lost his entire close family to meningitis. In that year his wife, three daughters, and one adopted child all succumbed to this bacterial infection of the brain. People respond in all sorts of unique and interesting ways after epic tragedies, and A.T. Still decided to re-think the principles of medicine as a result. This was at a time of bloodletting and leeches and “heroic medicine”. This was a time when doctors were supposed to do something and not “just stand there.” So they did things–ALL the things–to treat patients even when those things didn’t help. Bloodletting and leeches will not cure bacterial meningitis and A.T. Still was understandably frustrated by this. He thinks, “there must be a better way!” and the seeds of osteopathy were born. Let’s dive a bit into A.T. Still’s medical background. According to my research as well as my recollections from learning a bit of this history in medical school, A.T. Still did not have a formal medical degree so far as anyone can tell. In that time (again the 19th century), in the U.S. a person practicing medicine without a formal degree was not all that uncommon and was a problem we’ll talk about a bit later here. AT Still appears to have apprenticed to some degree under his father who was apparently a physician. After spending some time with his dad he entered into service in the Civil War with company F out of Missouri, on the side of the union. He was a hospital steward it would seem and would later describe himself as a “de facto” surgeon. In other words he was pretty much a surgeon by Civil War standards, just minus all the formal training and stuff so that should inspire confidence. Nevertheless it was not uncommon for hospital stewards in the Army to be promoted to roles like surgeon, especially given the awful circumstances in the medical encampments during that war. Stewards often functioned as pharmacists and all manner of general medical staff at that time. After the war is when his family dies and he begins to devote himself to medical complementary areas of study. Notably he was an avid anatomist and articles describe him as being a meticulous dissector person. Indeed, anatomy is emphasized as a foundation of osteopathic training because, as we’ll see, it’s at the root of many osteopathic principles of treatment. It should be noted that AT Still did seek out further medical education. He completed what was described as “a short course in medicine” at the then new College of Physicians and Surgeons in Kansas City, MO in 1870. I’d like to imagine this was a correspondence course or something to that effect. I’m not really sure how short the course was or what was covered, but I believe this is the last formal medical training he seemed to receive prior to founding osteopathy. In 1874, the very same year that had many exciting historical developments such as the 1st zoo opening in Philadelphia, Hary S. Parmalee patenting the sprinkler head, and the formation of the World Postal Union in Bern, Switzerland (finally, right?), A.T. Still “flung to the breeze the banner of Osteopathy.” I feel compelled to use those words which come from his autobiography partly because who can refuse such poetic grandiosity. I guess it sounds better than “I made up a new kind of medicine in response to a personal tragedy.” What is osteopathy exactly? Etymology nerds will note that the word means “bone pain/suffering,” more or less–osteo is bone, pathos is a bad thing. AT Still’s basic tenets of osteopathy included the following:
What this meant in the context of osteopathy as a new way to do medicine was the belief that the musculoskeletal system is the foundation of health and that proper functioning and diagnosis thereof is the key to treating disease. If the MSK system is out of wack, anatomically speaking, so too will other body systems malfunction–and vice versa, that if a problem arises within the intestines, one might find evidence of this is the MSK system and soft tissues. I’ll pause to let that wash over my MD colleagues here. Maybe I should add that AT Still, around the time of banner flinging, was really into spiritualism. Practically speaking, in the beginning, osteopathy was a purely manual manipulation type of practice. AT Still believed that an in-depth exam of the patient’s spine and other joints might give insight into whatever medical maladies they might have. Also, by manipulating the spine and other joints and soft tissues into a more normal alignment, one would improve the overall health of the patient. When the MSK and soft tissues are pathological or seemingly communicating an underlying pathology, this is referred to as “somatic dysfunction.” By the same stretch of the imagination, one could also do an exam of the MSK and soft tissues to find out what is happening with the internal organs. In the early days of osteopathy, this focus on manual medicine, so-to-speak, also meant traditional medications were eschewed. Granted, mercury containing calomel, arsenic, and the piles of opium that were typically prescribed around the end of the 19th century did not save people from things like bacterial meningitis, but I don’t think a good alignment of one’s spine and joints would either. Over time–extending into the present day–osteopathic manipulative medicine (OMM) evolved several general types of diagnosis and treatment. In osteopathic medical school, we as students had all of the normal medical school classes–anatomy, physiology, pharmacology, pathology, etc.--but in addition would have a 4-hour class every week in OMM principles and treatment, many of which derive from the writings and teachings of AT Still and his subsequent early osteopathic disciples. I won’t say that my views on the matter speak for all DOs, but when people ask me to describe what OMM is, I like to say it’s a spectrum of things that may have some semblance of physiologic plausibility to the embarrassingly pseudoscientific nonsense that should be called for what it is. Though manipulative medicine was once the only thing osteopaths did as medical intervention, we’ll see that over time this has come to be a very small part of DO practice in the modern day. On the possibly reasonable side of the spectrum would be “muscle energy” techniques. In the simplest sense this involves taking a joint to a position of restricted movement, having the person contract the muscles that move the joint against resistance, allowing a period of relaxation, and then stretching the joint to move further than it did beforehand. The process is repeated and the goal is to see increased movement and decreased discomfort in the area in question. Aside from the hokey name, this type of thing is performed by physical therapists as well as DOs. This is the one and only thing I ever use on myself, typically to get a good stretch before playing hockey. Towards the middle of the spectrum would be things like HVLA treatment. This is where a person is positioned in a variety of ways to try and take a spinal segment (though it can be used on other joints) into a position of restricted movement and a short thrust is made to move the segment a small distance at a quick pace. This often gets a little crack out of the joint and the underlying malady is cured. If this makes you think of a visit to the chiropractor’s office you’re not far off as there is a lot of overlap in what osteopathic and chiropractic techniques seem to look like. This is perhaps because D.D. Palmer, the so-called father of chiropractic medicine, wrote about taking a course in osteopathic medicine in 1899 so I can’t help but think these two bits are related. There will be many in the DO world that might take issue with that, but I would say it’s my opinion that there is not much sunlight between HVLA treatment and chiropractic treatment. In practice DO’s, including myself of course, are taught a system of pressing on the spine and surrounding soft tissues to see if a vertebral segment seemed to be rotated oddly or bent strangely and try to put it back into its proper place. I put this in the middle of my spectrum of plausibility because there is at least some research to suggest OMM may help with specific low back pain patients. At the far end of the insanity spectrum is cranial osteopathy. This was where I, and many of my DO med school friends had a career choice existential crisis. I recall sitting in a vast lecture hall–the same one that held amazing lectures on neuroanatomy, microbiology, and pathology–and being presented with the principles of cranial osteopathy. Developed in the 1930s by Dr. William Garner Sutherland (DO of course), the tenets of cranial osteopathy hold that contrary to all known anatomical knowledge, the bones of the skull which fuse together in early childhood, around the age of two, are actually capable of movement. There is the belief that there is an underlying Cranial Rhythmic Impulse that can be felt 8-14 times per minute as the cerebrospinal fluid surrounding the brain pulses to and fro. By feeling the amplitude and rate of this CRI, one skilled in cranial osteopathy can diagnose underlying pathology or try to treat it by restoring the pulse to normal. I was sitting in class while this was being described and I, as a staunch skeptic then and to this day, was horrified. It will not surprise you to find out that despite many, many, many efforts to prove the concept, the CRI has not been demonstrated to exist and skull bones do not move to any perceptible degree. Many prominent DOs have spoken out or written about the need for osteopathy to stop teaching this. I share that opinion as you might imagine because this is absolutely bunk and does not belong in a medical school curriculum outside of mention as a historical part of the profession that was, medically speaking, complete nonsense. Myself and several friends and colleagues actually refused to participate in practice of this during our OMM classes towards the end of medical school. With those principles in mind, we’ll return to the story of how DOs gradually became respected members of the medical profession. From the founding of the American School of Osteopathy in Kirksville, MO by AT Still himself in 1892 until the 1950’s or so, DO medical practice was purely OMM treatments. DO schools did not start teaching the principles of pharmacology at all until 1929, over ten years after the death of A.T. Still in 1917. I’m not sure he would have liked that. In the early 20th century, however, DOs started to adopt more and more principles of traditional MD medical training and the profession moved to legitimize itself in the house of medicine. This was a long, uphill battle for the better part of the last 100 years. The first test was, fittingly, passed by the DO schools themselves. I mentioned the problem of the whole “how to be a doctor” thing being too unregulated earlier. This was a major problem in the US in the early 20th century. To codify and improve medical education, something called the Flexner report was released and it called for a systematic way to vet and credential medical schools and the education of physicians in general. Though the DO schools of the time did not teach a curriculum identical to their MD counterparts, they did have rigorous study of anatomy and physiology and, with some adjustments, were able to survive the fallout from the Flexner report. To put it into perspective, there were 155 medical schools in the US in 1910 at the time of the report’s release. After the report, 31 schools remained standing and able to graduate doctors. Many of the early DO schools were among them and are still in operation to this day. This was a big step towards legitimizing DOs in medicine. In the 1950’s, osteopathic practice started to incorporate more concepts of what we’d call primary care. Many DOs went into family practice while still doing manipulative medicine. Though pharmacology was regularly taught in DO schools for the prior 20 years, there were some interesting growing pains. While I was in medical school, one of my neighbors was a long-retired DO who graduated in 1955. He took my wife and I out to dinner once and told us a bunch of amazing stories, including the fact that in the 50’s, where he practiced, he would have to contract with an MD to sign his prescriptions to make them official. Different times to be sure. It was in the 1940’s and 1950’s that DOs found themselves butting heads with MDs and the American Medical Association in general. As recently as 1961, the AMA code of ethics had declared it “unethical for a medical physician to voluntarily associate with an osteopath”. Prominent MDs in the AMA wrote about DOs in rather unflattering terms. In 1954, osteopathy was described as “cultish” in a paper by Dr. Charles L. Farrell, M.D. who opposed cooperation between MDs and DOs. He, and many others, pointed to what they deemed to be pseudoscientific practices within OMM and what appeared to be staunch adherence to A.T. Still’s principles of medicine despite evidence to the contrary. Farrell’s objections included a citing from a 1952 osteopathic textbook which stated “A.T. Still’s discoveries have been ‘progressively confirmed’ and ‘never invalidated.’ To that effect I can empathize with where these MDs were coming from in this regard. From 1916 to 1966 osteopaths were in a “long and tortuous struggle” to serve as physicians and surgeons in the military as one article put it. DOs were not allowed to have practice rights in the US military during WWI and WWII. This changed when on May 3rd, 1966, Secretary of Defense Rob McNamara authorized DOs to be accepted into all military branches on equal practice basis as MDs. This was a big step for the DO profession. As DOs were practicing more traditional medicine, what with all the pharmacology and stuff, there were a few more hiccups with the AMA in the 1960’s. A notable example took place in California in the 1960’s where not much else was going on, historically speaking. The AMA, at that time, spent $8 million dollars to stop osteopathy in the state. Proposition 22, a statewide ballot initiative, barred DOs from practicing in California. The California Medical Association offered to issue DOs an MD degree if they payed a $65 fee and took a “short seminar” to bestow them with MD-ness, I guess. 86% of the DOs at the time in California took them up on the offer. I don’t know how much of that was due to needing it to practice medicine at all in CA at the time, or how much was a rebuke to keeping the DO degree and identity separate. The AMA re-accredited the University of California at Irvine College of Osteopathic Medicine as University of California, Irvine School of Medicine (MD School) and banned the issuing of MD licenses to DOs moving to Cali from out of state. This all stood until 1974 when protests and lobbying of the California supreme court by prominent DOs allowed osteopathic licensing to resume in the state. As an aside, the DO degree was not uniformly recognized in all US states until 1973. By 1969, the professional rift between DOs and MDs starts to mend. That year, it was approved that DOs can be part of the AMA and DOs were also allowed to participate in MD residencies–not allowed before this. Interestingly, the American Osteopathic Association (our AMA, if you will) rejected the measure to let DOs go to MD residencies. There were efforts then, and some still now, to keep the DO degree and approach to medicine as a whole, as a separate and distinct identity. At the time I attended and graduated from residency, I had to make a choice whether to apply to DO residiencies or MD residiencies, opting for the latter. I had to take two sets of boards (MD vs DO boards are different) and many of my compatriots had to make similar choices. In 2014, however, the AMA and AOA merged the residency process removing the distinction. I see this as a very good thing, personally. With that gradual evolution, the DOs of today are interchangeable with MDs in all other aspects. Several of my classmates are in all the fields and hypersubspecialties of medicine. This has led to an interesting question of what, in the modern era, makes the DO degree and DO physicians all that different. According to a study from the Journal of Osteopathic Medicine done in 2021, the data suggests the use of osteopathic manipulative medicine in practice is declining. This was definitely the case when I was in school, too. Of 10,000 surveyed DOs in that study, only 16% responded and of those, ¾’s of themused OMM on less than 5% of their patients and just over half did not use OMM at all. So if DOs are not practicing OMM much at all in the real world, what is the distinction of the DO profession at this point. Why have a separate degree at all? I do have strong opinions on the matter but this is a history show so I’ll spare them–I suspect many listeners might guess what I think. I should also mention that osteopathy and the practice thereof as a medical provider may look very different in other countries. While D.O.’s may have full practice and prescribing rights in the U.S., Canada, and many, many other countries, some countries do not allow DO’s to practice in such ways–France as an example. In this regard, DOs can only practice manipulative medicine and not prescribe. My final thought, and the reason I wanted to do a show on the history of my own degree, is to leave you all out there with a positive impression. The historical origins of the degree are certainly interesting and worth remembering, but many of the pseudoscientific concepts that may have been taught–or might still be taught–in the world of OMM are far from defining features of osteopathic training. DOs are in every area of medicine doing incredible work. DOs have been surgeon generals and are every bit as capable as our MD colleagues. So if you notice your doctor is a DO on your next visit, perhaps you’ll know a little more about why initials following their name are just a bit different. In the end, a good doctor is a good doctor. Sources: https://books.google.com/books?id=H08EAAAAMBAJ&q=andrew+taylor+still+lightning+bone+setter&pg=PA108#v=snippet&q=andrew%20taylor%20still%20lightning%20bone%20setter&f=false (Life article about AT Still) https://quackwatch.org/chiropractic/rb/bcc/8-2/ (Farrell comments on osteopathy) https://pubmed.ncbi.nlm.nih.gov/22331804/ (DOs not able to serve in WWI and WWII as docs). https://en.wikipedia.org/wiki/Osteopathic_medicine_in_the_United_States#History (General overview) https://en.wikipedia.org/wiki/Andrew_Taylor_Still (AT Still’s life overview) https://www.amboss.com/us/knowledge/Cranial_osteopathy/ (Cranial stuff) https://bmjopen.bmj.com/content/12/4/e053468 (Summary of research on OMT) https://pubmed.ncbi.nlm.nih.gov/33512391/ (OMT use in US nowadays) https://www.aacom.org/become-a-doctor/about-osteopathic-medicine/history-of-ome (timeline of notable DO historical events) Max Doctor with a mustache. During the French Revolution, after seeing the speed with which the carriages of the French flying artillery maneuvered across the battlefields, French military surgeon Dominique Jean Larrey applied the idea of ambulances, or "flying carriages", for rapid transport of wounded soldiers to a central place where medical care was more accessible and practical. Larrey operated ambulances with trained crews of drivers, corpsmen and litter-bearers and had them bring the wounded to centralized field hospitals, effectively creating a forerunner of the modern MASH units. Dominique Jean Larrey is sometimes called the Father of Emergency Medicine for his strategies during the French wars. Emergency medicine as an independent medical speciality is relatively young. Before the 1960s and 1970s, hospital emergency departments (EDs) were generally staffed by physicians on staff at the hospital on a rotating basis, among them family physicians, general surgeons, internists, and a variety of other specialists. In many smaller emergency departments, nurses would triage patients, and physicians would be called in based on the type of injury or illness. Family physicians were often on call for the emergency department and recognized the need for dedicated emergency department coverage. Many of the pioneers of emergency medicine were family physicians and other specialists who saw a need for additional training in emergency care.[11] During this period, physicians began to emerge who had left their respective practices to devote their work entirely to the ED. In the UK in 1952, Maurice Ellis was appointed as the first "casualty consultant" at Leeds General Infirmary. In 1967, the Casualty Surgeons Association was co-established with Maurice Ellis as its first president.[12] In the US, the first of such groups managed by Dr James DeWitt Mills in 1961, along with four associate physicians; Dr Chalmers A. Loughridge, Dr William Weaver, Dr John McDade, and Dr Steven Bednar, at Alexandria Hospital in Alexandria, Virginia, established 24/7 year-round emergency care, which became known as the "Alexandria Plan".[13] Maurice Ellis Blue Plaque Unveiling It was not until Dr. John Wiegenstein founded the American College of Emergency Physicians (ACEP)(https://www.annemergmed.com/article/S0196-0644(04)01836-0/fulltext#relatedArticles) the recognition of emergency medicine training programs by the AMA and the AOA, and in 1979 a historic vote by the American Board of Medical Specialties that emergency medicine became a recognized medical speciality in the US.[14] The first emergency medicine residency program in the world began in 1970 at the University of Cincinnati.[15] Furthermore, the first department of emergency medicine at a US medical school occurred in 1971 at the University of Southern California.[16] The second residency program in the United States soon followed at what was then called Hennepin County General Hospital in Minneapolis, with two residents entering the program in 1971.[17] 1961: James Mills Jr MD started full time ED practice in Alexandria VA. At this time there are only hundreds of ED physicians in the country. 1966: Trauma surgeon report calling ed "the weakest link in the chain of hospital care". THe National Academy of Sciences released Accidental death and disability:the neglected disease of modern society which noted injuries killed 107,000 yearly. 1968: Dr. John Wiegenstein and Dr. Eugene Nakfoor (lansing MI) founded ACEP 1969: ACEP's first scientific assembly with 128 physicians attending 1970: FIrst ER residency (Cincinatti General). First resident was Bruce Janiak. Dr. Herbert Flessa was a young hematologist that wanted to improve emergency care. Initially approved under family medicine. 2 year certificate program. 1972: University of Louisville, University of Chicago (rosen) 1975: 31 Residencies 1979: ER named 23rd medical specialty by American Board of Medical Specialties 1980: First board certified ED physicians The ER began after the second world war. Fewer home visits, office hours, urban sprawl made it harder to deliver quality care. Hospital based medicine increased. Usually a small room with a single nurse. Currently there are 48,835 active emergency physicians. Median age is 50. Sources: Emergency Medicine Documentary: https://www.emra.org/about-emra/publications/legacy-documentary/#247365documentary https://www.acep.org/static/globalassets/resources/content/horizontal-timeline/index.html https://www.history.com/news/americans-once-avoided-the-hospital-at-all-costs-until-ers-changed-that https://elischolar.library.yale.edu/cgi/viewcontent.cgi?article=1056&context=ymtdl Mike AKA Dr. Provolone Killer Fungi
Transition–what about fungus in medical history? We are a historical podcast after all Historical Fungus Story–even one damn fungus caused a bunch of trouble (claviceps purpura), or does it? Ergot and Salem
Transition: ergotism does cause a long-standing medieval affliction called St. Anthony’s Fire, which spawned a whole hospital system run by monks
References:
Aaron Silver Fox Doc On the heels of our case discussion in the prior Princess Diana episode, we’d like to discuss another famous medical case having received lots of good feedback on that episode. So let’s talk about another case–one that involves a personal hero of mine, Erich Weisz. You may know him as the one and only Harry Houdini. I’m curious, without prompting, do either of you know how Houdini died? Many people know Houdini as a magician and escape artist. He was very much those things. But Houdini was also a world renowned debunker. With his vast knowledge of designing and performing illusions, Houdini was especially adept at confronting and exposing psychics and spiritualists who, popular as they were at the time, would take money in exchange for pretending to contact a person’s family members or other loved ones. He was on a personal crusade against this practice as he saw it as fraudulent and predatory. A full re-telling of Houdini’s life is beyond the scope of this medical history show, but I’ll do a brief summary here to set the scene. He was born Erich Weisz in Budapest, Hungary in 1874. His father was a Rabbi and the family moved to the U.S. on July 3rd, 1878 and landed in, of all places, Appleton, Wisconsin! He later moved with his family to good ol’ Milwaukee. As a child, a young Erik Weiss saw a magician named “The Bloodless Vivisectionist” at the “Dime Museum”, described as a “lurid theater” on Wisconsin Avenue. This place sounds absolutely fascinating by the way. The magician used knives to appear to dismember a volunteer from the audience in front of a live crowd before using a flourish to end the show and replace his victims' apparently amputated appendages. A young Houdini was hooked on magic as his future career. I only wish my own career origin story was half that interesting. Erich is pursuing his dream of professional magicianship (totally a word) and starts calling himself “Harry Houdini'' after reading the biography of Jean-Eugene Robert-Houdin in 1890. I’m going to gloss over a lot of his life but it’s good to appreciate that Houdini was far from successful when he started. He was apparently okay at sleight-of-hand stuff but not exceptionally gifted. He could, however, escape from a pair of handcuffs and his break came in 1899 when he impressed a manager named Martin Beck in St. Paul, Minnesota by doing so. As he focused on creating and performing more and more dangerous escape acts, his popularity skyrocketed him to eventual international fame. His escapes were truly incredible. Some of the more notable ones included the water torture cell where he would be suspended by locked manacles head down into a sealed water chamber, having to escape out. He did an escape from a nailed and rope tied packing crate after it was tossed into NYC’s east river. He had handcuffs and leg-irons on for that one and the thing was weighed down with 200lbs of lead. Took him 57 seconds to get out, apparently leaving the crate intact with the manacles inside. And, of course, there were his buried alive stunts where he would be, well, buried alive and have to escape in front of the crowd. In Santa Ana, California in 1915, on his first attempt at this trick, he almost died. He panicked and was trying to dig his way to the surface, collapsing just as he broke his hand through and had to be pulled from his grave by assistants. To be clear, these were acts, but they were very dangerous and more than a few magicians have died trying to reproduce Houdini’s escapes. The other fascinating part of his career was as an incredible debunker of mystics. Houdini, though he could make people believe in the impossibility of his spectacles, was an ardent skeptic and in his later career would go on to make spectacles of exposing so-called psychics and mediums. There is so much more to this part of the story that I’ll leave alone, lest I be distracted away from the medical history of this story, but I would encourage everyone to do their own deep dive on Houdini. With that all being said, let’s get to the medical case. Among all of his death defying escape acts and professional psychic busting, Houdini had a bit he would do where he would challenge people to punch him in the stomach. If you’ve ever seen pictures of Houdini you’d appreciate that he was, medically speaking, jacked. Especially for the time, Houdini had a strong physique and this included a set of abs able to withstand punches–if he was prepared. In Montreal, Canada, on Oct 22nd, 1926, Houdini was backstage prior to his performance that night, kicking back on a couch. He was in the company of three local medical students from McGill University, which has been mentioned more than once on this show. He’s lying on the couch because he had apparently broken his ankle in a prior recent performance. The topic of his ability to withstand punches to the abdomen comes up and one of the medical students named Gordon Whitehead asks if it’s true that Houdini can’t be hurt by gut punches. Houdini says it’s true and either invites Whitehead to try or Whitehead just assumes he can give it a go. While Houdini reclined on the couch with a broken ankle, Whitehead delivered “some very hammer-like blows below the belt” well before Houdini’s abs could be tightened. Below the belt means lower abdomen in this context, FYI. Belts were just higher back then. Houdini is described as appearing to be in significant pain after this, has Whitehead stop and manages to carry on with his performance. He spends two days in constant pain but travels from Montreal to Detroit, Michigan on Oct 24th, 1926 for his next scheduled show. As his abdominal pain is not improving and severe, he goes to a doctor before that performance and is apparently told he needs immediate surgery on his abdomen. He has a fever of 102 degrees at that time. He politely declines and goes to the Garrick Theater in Detroit to carry on with his performance. By the time he takes the stage, his fever is up to 104 degrees but even this does not stop him. He is described as ill-appearing and making uncharacteristic mistakes during the performance. One account even has him passing out and being revived prior to ending the show. He makes it through the show and returns to seek medical attention at Detroit’s Grace Hospital. He is admitted to the hospital with fever and abdominal pain and, for reasons not entirely clear to me, days go by until he undergoes an operation. Upon opening his abdomen they find he has diffuse peritonitis (describe) from what appears to be acute perforated appendicitis. The surgeon does a wash out and Houdini survives for the time being. He apparently is still spiking fevers so days later he returns to the operating room for a second washout of his abdomen. Unfortunately this does not help and on Oct 31st, Halloween, 1926, Houdini dies from sepsis and overwhelming infection at age 52. It wasn’t a magic trick gone wrong. It was a common diagnosis that ended his life. But while appendicitis is common enough, I think you guys will agree that this is a really unusual story for this, correct? Let’s talk about the way appendicitis should work to highlight why this is strange and see if we can explain this. I think it’s fair to say most listening to this show have heard of appendicitis. I’ll go ahead and guarantee that more than a few of our listeners have experienced this diagnosis and are living perfectly normal lives without their appendix at this very moment. The appendix is a noodly appendage of sorts that hangs off of the first part of your large intestine, called the cecum, in the right lower part of your abdomen. It’s typically about the size of an average pinky finger and is a meaty hollow tube with a closed end and an open end where it attaches to the large intestine. Appendicitis happens when material (read poo) plugs up the opening to the appendix causing it to close off and become inflamed with bacteria. It swells up, becomes painful and, if left unchecked, will expand with infection to the point it falls apart or “ruptures” causing bacteria and pus to spill into the inside of your abdomen, causing rampant inflammation of the lining of the abdomen which is called peritonitis. The pus and bacteria, if still left unchecked, will work their way into the bloodstream and overwhelming infection and its ill effects on the human body–something we call sepsis–ensue until death. Today we perform surgery promptly to try and remove the swollen/infected appendix before it ruptures as we know people can live without it. But there is a reasonable question to ask before you remove a part of the body–what does it do? Good question. This is an area of some debate. We are not the only creature to have an appendix suggesting there is or may have been some useful function served. While there is a camp that believes the appendix is a purely vestigial organ–one that is no longer used thanks to the tides of evolution–there is an emerging camp of research that suggests the appendix may be a healthy bacteria storage unit for the large intestine, keeping and harboring bacteria helpful to the functions of the large intestine. There is a third camp of cynics that proposed that the appendix exists only to provide college funding for the children of surgeons. As neat as all that may be, it does stand that people can live perfectly normal lives without this colonic danger noodle. A neat offshoot of researching this case was finding out a bit about the history of the appendix and diagnosis and treatment of appendicitis. Let’s talk about that for a bit and we’ll return to Houdini’s death. Appendicitis has been around–like many things–for ever. As long as there have been appendixes there have been appendicitiseses. One article I’d reviewed recalled the example of an Egyptian mummy that was opened to discover scar tissue and evidence of peritonitis in the right lower abdomen suggestive of appendicitis. But it took awhile to coin the name of this diagnosis. Surely there were many cases of people likely dying from this intra-abdominal infection over the past thousands of years, but it took some time not only to identify the appendix as the cause, but also just to identify the appendix as a structure at all. You might say that much like Houdini, the appendix escaped the attention of anatomists and surgeons for hundreds of years. It certainly escaped Galen’s attention. You might remember him as the famous Greek physician that couldn’t perform dissections due to cultural norms of the time and therefore made up a bunch of nonsense about medicine that was followed as gospel for over a thousand years. He did mention a condition causing right lower quadrant pain and subsequent illness but never mentioned the appendix as a structure of note–though he did do dissections of gorillas and whatnot. In ancient times, medical texts would describe cases of what we now know to be advanced appendicitis wherein the abscess (think boil) that formed inside the person’s abdomen could, at times, grow to poke through the abdominal wall, draining to the outside. I can only imagine how astonishing it would have been for people to just start expelling pus from their abdomen which was now open to the outside world in this case. People did, sometimes, survive when that happened because the infection essentially escaped, but much of the time, as one surgical history article put it, they would “die a peaceful death” from sepsis. I feel like “peaceful” is doing a lot of lifting in that sentence. By the Renaissance period, at least the appendix was being named as its own structure. First descriptions of appendix appear in the late 15th, early 16th centuries. Before he was swinging around katanas and eating pizza, Leonardo Da Vinci drew an appendix among his anatomy drawings in 1492 though it was not published until the 18th century and Da Vinci did not give it a distinct name. Berengario Da Carpi, a professor of surgery at Pavia and Bologna, Italy in 1522 was the first to give the appendix some sort of name. Andreas Vesalius, who has been mentioned before in a few episodes, in 1543 illustrated the appendix in his work “De Humani Corporis Fabrica”, but called it “the cecum” and helped confuse terminology for a while to come. In other words, though he illustrated it, he felt it was just a part of the large intestine and not its own sovereign anatomical structure. I’ve included a picture here in the notes for my co-hosts and will include it on our website with show notes. Moving ahead to the Age of Enlightenment, we have the appendix not only verified as a thing, but physicians and surgeons start to question its function. They still haven’t, at that time, realized that the appendix is a source for the abdominal infections they’d see from time to time. In 1735, a surgeon by the name of Claudius Amyand is credited with performing the first appendectomy–albeit the story is strange and it’s not as if he did the surgery trying to remove the appendix. He performed a surgery on an 11 year old who had developed a painful inguinal hernia. This is where a portion of the intestines escapes the abdominal wall and, as is often the case in males, slithers down the groin to get stuck in the scrotum. It just so happens that the hernia here involved the cecum and attached, inflamed appendix which Amyand removed successfully. A hernia containing the appendix is still called an Amyand’s hernia if you’ve ever heard the term. Basically, he cured a case of appendicitis by doing surgery for another reason. We call this failing correctly. By the late 18th century, famous surgeons like John Hunter of England were describing case after case of right lower quadrant intra-abdominal abscess and even abscess surrounding the appendix, but they still were not connecting the fact that the appendix itself was the cause of these infections. In the 19th century we start connecting the dots. Here come some big-time name drops–at least for medical history nerds. In the early 19th century, Dr. Baron Guillaume Dupuytren–a leading surgeon at the Hotel Dieu’ in Paris–associated right lower quadrant inflammation/abscess with “cecal pathology”, meaning he realized it was starting at that part of the large intestine where one finds the appendix. This was echoed in a graduation thesis published in 1830 by Dr. Goldbeck called “Inflammation in the Right Iliac Fossa” which described all the signs of appendicitis but attributed it to arising from the large intestine, not the little wormy-looking appendix. So close. In 1848, a surgeon named Dr. Hancock performed abdominal surgery with the then new-fangled chloroform anesthetic, draining an abscess that had formed around the appendix, but before it had grown large enough to poke through the abdominal wall and drain to the outside. Almost 20 years after that, in 1867, Dr. Willard Parker writes about four cases of peri-appendiceal abscess drainage–purposefully waiting a few days for symptoms to develop, but trying to do surgery before the abscess inside the abdomen had grown large. This starts the thinking that treatment for appendicitis may be earlier and earlier surgical intervention which definitely did improve the mortality of this illness. Finally, in 1886, a Harvard pathologist named Dr. Reginald Herber Fitz presented a paper to the American Association of Physicians called “Perforating Inflammation of the Veriform Appendix” and he said plainly that the cause of most right lower quadrant inflammatory abdominal disease is perforated appendicitis. He also recommended the appendix be removed prior to becoming an abscess when the diagnosis is suspected and this is still the standard of care today. The year after, in 1887, Dr. Thomas Morton performs the first successful operation deliberately to treat the now titled diagnosis of “appendicitis”. He had been treating a 26 year old male patient who he ultimately took to the operating room after a week of calomel, soda water, stimulants, quinine, warm compresses, and good ol’ fashioned medical leeches failed to treat the appendicitis. He opens the abdomen, finds an abscess around the appendix, cleaned out the pus and removed the appendix as well. He irrigates (washes) out the abdomen and the patient recovers well. Regarding this operation, a contemporary of his named Dr. Chapman wrote about the case and gave his thoughts on the manner of whether or not this little organ should be removed: “A true veriform appendix is found only in six animals: man, gorilla, chimpanzee, orangutan, gibbon and wombat. There can be no doubt, therefore, that the cecal appendix is one of the parts of the human body having no particular function of significance, being of use only in animals… In the human being it ought to be removed with no bad effect whatsoever, so that I thoroughly agree with Dr. Morton in what he has to say regarding the opening of the abdomen and taking out the appendix. It seems to me that the human being is better off without the appendix than with it, for it is nothing but a trap to catch cherry stones and other foreign bodies.” I feel compelled to mention that Dr. Morton’s brother and his son both died of appendicitis prior to this. The last name drop prior to returning to Houdini’s case is that of the surgeon, Dr. Charles McBurney, a US surgeon who, in 1889, described the classic case of appendicitis we all learn as physicians. Pain starts typically around the umbilicus which intensifies and moves to the right lower quadrant as the appendix becomes more inflamed and touches the abdominal wall, accompanied by nausea, vomiting, unwillingness to eat and fever. Though this is how the textbook teaches the diagnosis, I think I’ve seen this exact presentation 2-3 times in the probably 100+ times I’ve diagnosed appendicitis over the last 10 years. Is this your experience as well, gentlemen? So with that classic but uncommon story for appendicitis in mind, let’s return to Houdini. It’s 1926 and he shows up to the hospital in Detroit with a fever and a concerning lower abdominal exam. I don’t think any of us would hesitate to make this diagnosis given those findings. You see that patient, get some bloodwork, and you call the surgeon with your classic exam. Your surgeon invariably agrees with your suspicion and asks for a CT scan anyway. The scan confirms appendicitis and can tell us whether or not the appendix has ruptured. We put the patient on IV antibiotics and they go to an operating room urgently to have the appendix removed. If it is ruptured, the pus is cleaned out and antibiotics are continued to quell any worsening of the infection. In Houdini’s time, antibiotics had yet to be discovered so that wasn’t an option. In uncomplicated cases, patients may be discharged the next day. While they used to do a large incision in the right lower quadrant for this, nowadays a tiny pair of incisions is made and laparoscopic tools are used to remove the appendix and minimize wounds to the abdomen, allowing a really speedy recovery when all goes well. It’s good to be in the modern age. I think the interesting question in Houdini’s death is what about the punches to the abdomen? Did they have anything to do with this final diagnosis? What do you guys think? There appears to be two main schools of thought on this matter. One is that Houdini, being the consummate showman and performer, may have developed the early signs of appendicitis but minimized the symptoms, rendering the punching of the abdomen as a red herring that had nothing to do with it. He carried on with his performance until his symptoms advanced to the stage that he presented with ruptured appendicitis. Whether this is the case, it should be noted that his final performance in Detroit was likely done with a ruptured appendix. That is some pain tolerance. I can’t know for sure, but after researching this episode, I actually think there is plausibility that the punches to the abdomen did have something to do with this. Looking through multiple sources for medical case reports I discovered numerous reports of trauma associated appendicitis. In reading these, it seems that direct trauma to the lower abdomen, if able to strike and compress the appendix or adjacent large intestine, can cause perforation, thus allowing the colon bacteria to escape and start inflaming the appendix. This progresses to appendicitis but appears to start because of the trauma. One systematic review of the literature found 28 cases of trauma induced appendicitis from 1991 - 2009 (various causes of trauma–falls, MVC, strike to abdomen). One of the most fun case reports I found of this was a case of traumatic appendicitis thanks to a well-delivered camel kick. I cite this as my favorite evidence to support the claim that Houdini had trauma induced appendicitis. I will link this in the show notes, of course. Well, that’s the story of the unfortunate end of Houdini and the history of appendicitis. Were you guys not entertained? Sources: -https://www.thehistoryreader.com/historical-figures/death-escape-artist-harry-houdini-appendicitis-surgery/ -https://cbc.org.br/wp-content/uploads/2014/02/02012014-AS.pdf -https://en.wikipedia.org/wiki/Harry_Houdini#Death -https://pubmed.ncbi.nlm.nih.gov/28673696/ (Appendicitis due to MVC) -https://www.hindawi.com/journals/cris/2021/6667873/ (Appendicitis due to camel kick) -https://pubmed.ncbi.nlm.nih.gov/20513274/ (Systemic review of traumatic appendicitis cases)  "The She Wolves of Jülich", 1591. Image from Wikipedia. Many have heard about the infamous European witch trials that ironically took place during a time period we call the Renaissance (c.1450-1750). What you may be less familiar with were so-called werewolf trials, in which physicians of the day would play a part. When a person might be accused of being a werewolf, a physician or similarly identified medical expert of the time might be called into the trial to perform a physical examination to look for evidence of a “connection with the devil,” be it a skin mark or something that could erroneously be used against the defendant–whether they were accused of witchcraft or being a werewolf. Contemporary accounts from this time period describe a possible association between mental illness and the belief that one might be a werewolf. Numerous accounts exist describing individuals (even up to the 20th century) that may have expressed a belief that they were wolves, though these accounts are not necessarily suggestive of violent behavior but may include behaviors mimicking those of a wolf. The term for persons diagnosed with a psychiatric syndrome leading them to believe or act as if they are a wolf is called “clinical lycanthropy” and is thought to be very rare. The medical experts that were called upon to weigh-in on werewolf trials would help render an opinion as to whether the person on trial might actually be a werewolf or, more helpfully, might argue a type of insanity defense that attributed the person’s behavior with a mental illness, which could lead to an acquittal. I think we can all agree that court proceedings and medico-legal defense strategies make for dry werewolf fiction. Predatory, full-moon transforming, silver-bullet dodging lycanthropes may be more interesting in their fictional form. Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4090416/#R37 Max Doctor with a mustache. As we found in our recent episode, the medical origin story of the zombie seems to have originated in Haiti and associated Caribbean islands with practitioners of voodoo, a religious practice brought to the region by West African slaves, and has nothing to do with the flesh-eating, brains-seeking versions in popular culture. Travelers from the Caribbean during the 19th and 20th centuries told tales about persons who were transformed into living dead servants by evilly dispositioned “bokor,” voodoo practitioners believed to have the capability of creating zombies with special brews or potions. The zombie powders obtained from bokors seemed to always contain ground up puffer fish. This, in turn, contains tetrodotoxin, a substance within the pufferfish capable of causing full paralysis–including breathing–in high enough doses. It appears these powders were typically applied to the skin. Cases of persons claiming to have been declared dead only to be found on the streets years later with personality alterations have persisted into the 20th century. This has led to the theory that use of zombie powder may have induced a level of paralysis that appeared to medical practitioners of the time as consistent with death. Persons may have even been buried for a short time until the tetrodotoxin wore off. If they weren’t buried, they also may not have been breathing adequately if the toxin dose paralyzed the muscles of breathing. These factors may have lead to near asphyxiation and the low oxygen environment of a grave may have contributed to varying degrees of anoxic brain injury, a phenomenon that might explain why some of those purported to be zombies, seemed to be acting off or at least without the mental faculties that their families may have expected. This is all a far cry from the pop culture zombies we see in the media today. Max Doctor with a mustache. Much of the popular mythos of vampirism draws from Bram Stoker’s “Dracula,” a work written after he had done a deep dive on the European folklore of the time on the subject of vampires. Though medical conditions such as rabies, porphyria, and tuberculosis have been suggested as culprits in originating the myth of the vampire, a nutritional deficiency may have been to blame: pellagra. Pellagra occurs when people don’t get enough vitamin B3 (aka niacin). This vitamin is used for many cellular functions. We don’t absorb it well from corn, which became the main food staple for the peasant’s diet in much of Europe in the 18th century as it was imported from America. Pellagra was first recognized as a disease in 1735 and suspected then to be due to nutritional cause. Pellagra is described by the “four D’s”: dermatitis, diarrhea, dementia, and death. Dermatitis refers to skin inflammation and rash that can occur with exposure to sunlight with pellagra–easy to make that connection to vampires. Without niacin, neurons can degenerate leading to dementia and, curiously, a behavior called “pica”. Pica is the strong craving for non-food substances including dirt and ice and other unusual things. It’s been suggested that this may result in the apparent unusual cravings of the vampire. Severe pellagra can result in death. Notably, the vampire cannon seems to leave out the diarrhea aspect of this disorder. That’s probably a good thing. Journal Article: https://journals.sagepub.com/doi/pdf/10.1177/014107689709001114 Max Doctor with a mustache. Digitalis In 1785, an English physician, Dr. William Withering, published his account of experimentation with a collection of herbs he’d received from a witch. This stemmed from a patient he’d had who he was treating for “dropsy”, an old tyme term for edema or fluid under the skin, typically attributed to something we know today as congestive heart failure (CHF). Whether it is weakened by a heart attack, a viral infection, or many years of pumping against high blood pressure, a heart may start to pump inefficiently. Instead of moving blood around the body in a nice, orderly fashion, the blood backs up as it fails to move forward as well as it used to. This leads to the fluid part of the blood leaking out into areas like the legs (especially thanks to gravity) and the lungs, leading to the shortness of breath and fatigue that is associated with CHF. So when the 18th century doctor had his patient show up appearing to be improved from a mysterious plant mixture given to him by a supposed witch, the doctor was curious and visited her. He was given a sample of foxglove and pursued testing of it for many years before publishing the account. He gave it to 160 of his own patients with various conditions and noted it seemed to improve the dropsy. He described an active ingredient called digitalis that foxglove and many other plants contain. Today we know this medication as “digoxin” and it is still used to treat CHF in select cases. Digoxin affects the shifting of electrolytes into and out of heart cells with an overall effect of improving the pumping strength of the heart. This helps people move their blood through the kidneys and clear out all that edema. It’s a treatment but not a cure for CHF. Mind you that digoxin can be dangerous in toxic doses. Starting with nausea, poor appetite, and vision problems, high doses can cause kidney issues, dangerous electrolyte levels, and cardiac arrest. Nevertheless, Dr. Withering was keen to listen to the supposed witch in the woods who’d helped his patient and he ultimately helped legitimize–along with others–the use of this seemingly magical medicinal substance. Max Doctor with a mustache. Among the treatments that were recommended by witches (or those who may be accused of witchcraft in Europe dating back to the middle ages), one might find preparations of willow bark and/or leaves. The association between these parts of the willow tree and pain relief were made well beforehand–dating back to perhaps Mesopotamia, the ancient Egyptians, ancient Greeks, and Native Americans, to name a few. Many cultures noted that this plant had seemingly magical properties. Within the leaves and bark of the willow plant (and some others), it contains a type of molecule called a salicylate. By itself, it can decrease inflammation and swelling, thereby aiding in pain relief and decreasing fever. If you’re the type of person who likes to mix chemicals and do reactions, you might have been Felix Hoffman, a German chemist who is ultimately (though with some controversy) credited with combining salicylic acid with acetic acid while he was working at Bayer in 1897. This created acetylsalicylic acid which we know as Aspirin. In this more refined form, that willow derivative functions as a much better anti-swelling and anti-pain medication. It also happens to stop platelets–a portion of the blood that helps form clots–from clumping together. This led to its still continuing role as a cardiovascular medication. If clots aren’t bunching up in narrow arteries, one might expect fewer heart attacks or strokes to occur. Here we have another modern medication with part of its roots in the apothecary cabinet of your friendly, neighborhood medieval witch. Much better than the leeches and purging agents your medieval doctor may have recommended since the willow bark actually worked, after all. Max Doctor with a mustache. |
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